The College of Optometrists

given that dishing out antibiotics may increase bacterial resistance - is it worth prescribing cholamphenicol for such a mild infection?

Could a more rigourous regime be considered? For example - monitor for 4 days and only prescribe if it is not getting better by then? Or try hot batheith first? What abt the irritation - could you prescribe painkillers for it? And what about the watery discharge? Is there any other way to manange it without grabbing the antibiotics bottle? - also

from the above - at what px age would you prescribe antiobiotic drops? Or just leave it to a doctor?

I think the evidence is that it usually clears up just as fast without treatment. Therefore it depends on you. your relationship with the patient and their personality.

Most medics I know give chloramphenicol because the patient feels something is being done and because it lubricates.

Some GPs worry about aplastic anaemia in kids (they have usually spent some time in the states). There is no evidence for this. Can't remember the paper but it is in the top ten on Pubmed.

Hope this is helpful

Palfi,

I was asked to give a talk on chloramphenicol to some local pharmacists. I had to do some reading on the subject, and off the back of this I have written a review article for one of the optical magazines. I hope to send this off by the end of the week, to hopefully be in print in about 1-2 months.

Your concerns of risking accelerating the rise of bacterial resistance for treating a self-limiting condition are valid. It is also often a waste of time - hourly irrigation (cooled boiled water) to reduce bacterial load is likely to be just as effective + lid hygiene if chronic. A recent study by rose et al. in the lancet (sorry about the reference), found that about 90% of people treated with antibiotic had no quicker clinical recovery than those receiving placebo.

Prodigy, an online information resource for GPs (nb v.good generally) has 3 prescribing strategies for conjunctivitis, one of which is essentially what you propose, ie to only treat if it is not getting better on its own in a few days. I agree, but also suggest to consider immediate treatment if severe or if pt in poor health so that they cannot fight infections well. 95% of GPs prescribe chloramphenicol immediately for any suspected conjunctivitis - though this is not cost-effective based on the above study, and similar ones carried out previously.

Re aplastic anaemia - 1 in 50,000 when given systemically, particularly in babies as they cannot metabolise so it accumulates. No evidence of increased risk when topically administered (many epidemiological reviews). BNF state that concern for eye preparations is 'unfounded'. Cases have been cited, but these occur at no greater frequency than expected by chance. So much chloramphenicol is prescribed that a few casual associations are inevitable.

i usually give gutt.chloramphenicol or ung.tetracycline when there is muco purlent discharge and matting of eyelids-sign of true bacterial infection.I prefer gutt.sulphacetamide for babies.

Michael - thank you for your errudite help as ever. My friend is going up to Cardiff for her optometry this yr - she skips the first year as she has done optometry in Malaysia.

Thinking abt what you say - what abt giving px comfort eye drops for hourly instilation (more convenient). Then start chlor. after four days if no better. But if poor health or old (?) over 70? then chlor imediately. Children - again just comfort drops and refer to gp if unwell or not improving.

I had a lady the other day who had mild bacterial conjunctivitis whose symptoms relieved very quickly on saline drops (minims that I had to hand). I was surprised!

What abt hot water batheing ? Would this be effective?

I can't wait for your article !! I am trying to get to a workable protocol to deal with this. thank you -

I know this is not exactly relevant to the above but a friend of my son's had a week of school last year with conjunctivitis and I've had pxs take time of work with it .Does anyone else think this is a bit over the top or is it just me?

I've sent my kids to school with conjunctvitis as I don't think it warrnts a day off and apart from the initial problem on awaking I've never found it to significantly affect their vision.

depends on the type of conjunctivius is uppose. viral infections are much more contagious than bacterial and so depending on the job, it may warrant time off to stop it from spreading.

i would only suggest the chloramphenicl for a bacterial conjunctivitis if it was persistent( as palfi suggests). With kids, sometimes it is much more difficult to deterimine whether itis viral or bacterial and it may be worth giving the antibiotic regardless. any thoughts?

I think the issue with kids is contagiousness (is that a word!!?) rather than symptoms for the patient. Not sure about schools, but nurseries often require pt to be completely free of signs of conjunctivitis for 48 hrs before they'll let them back throught the door! I suppose time off work depends on the kind of work you do - if you are sitting at a VDU all day, you may be pretty uncomfortable.

Also an issue for optometrists, especially if you work alot with compromised eyes, such as hosptial work, or seeing post op cataracts for example - probably should be off work until completely clear.

Lisa

Palfi, I think that lubricants are a good idea, though its the quantity that's important rather than what it is. A large bottle of saline squeezed into the eye is useful, though minims have the advantage that it does not matter if their tips get contaminated. Re. temperature, I would have thought cooler would be better than warm; because it feels nicer, and warm water would increase vasodilation and the rate of bacterial multiplication. nb although I feel that most cases do not need medical treatment, if this is felt appropriate, then it should be aggressive to do something - a loading dose of drops 2 hourly for 2 day with ointment at night, and then drops 4 hourly with ointment in evening until 48h after clinical cure.

ljc, I agree - its not the symptoms that warrrent quarantine, but the risk of transmission. Conjunctivitis remains communicable whilst discharge remains.

bazzar, indiscriminate use of chloramphenicol has a 90% chance of not helping, whilst increasing the risk of resistance developing. If unsure, ie not grossly sticky, then it cannot be too bad - so I would not treat. If you feel that you must because the mother wants something done then prescribe frequent irrigation.

african eye, - where do you work to access those drops?

This discussion has realy helped to think about this topic, I am glad I brought it up.

Michael - I had a very interesting lady today with congen. non-functioning lacrimal glands - she has to use supplimentary tears. She did have the tell-tale 'tear' drop on upgaze although looking normally - tear prism was okay. It does seem a good sign of dry eye, and tosome extent predictive of fl. staining. This was interesting as her eyes had not 'adapted' to the lack of aqueous tears in her life (age 34. I think this idea is worth a look.

I treated a member of staff, who has bact. conjuntivitis with contact lens comfort drops (refresh) and monitored her each time I went for a coffee. Magic - getting better! I am getting more confidence!

I also had a chap called Ben who lost his spleen in an accident and takes amoxcillin per day long term. He has had long term changes to his commensal bacteria (guess) in the conjunctival sac causing him a chronic low grade conjuctivis-like symptoms. He's having a go with the Refresh as well, backed up with strict lid clensing.

thanks everyone :-) palf-itis

Just a PS despite sending my kids to school with conjunctivitis ,I'm not aware of their classmates being infected.I appreciate that having conj is a problem in some jobs, I'm still not sure people need take a day off.

But the patient was a man...need I say more!

Michael Jackson,

I am from Nairobi,Kenya.

Differential diagnosis is imporatnt,viral,allergic or even severe dry eyes can mimic signs of baterial infection.If it is true infection with mucu purelent discharge, low grade fever, then antibiotic should be administered.

sorry Michael Johnson,i incorrectly spelt you last name in aboe post.apologise.

Nursuries are quick to ask for drops on the slightest redness in the eye thinking it is conjunctivitis. Needs to be more education on this one.